Psychological distress is triggered when there is impairment in cognitive processing. Perception and interpretation become very selective and inflexible. The ability to rectify distorted thinking and perceptions through reality testing and refinement of overall conceptualisation is compromised. Psychological distress is characterised by what Beck and Weishaar (1989) described as cognitive distortions, a shifting of information processing highly influenced by the primal system, resulting in systematic errors of reason. These cognitive distortions include arbitrary inference, where firm conclusions are drawn in the absence of evidence or even presence of contradictory evidence. Selective abstraction is similar in that the individual will selectively acknowledge evidence out of context, which confirms a distorted conceptualisation of an event or situation. Over-generalisation of isolated, potentially unrelated incidents and creating a broader hypothesis from these events to be applied to a wider forum regardless of evidence is a further distortion. Thinking in absolutes, categorising events dichotomously with no continuum being acknowledged is equally common. Furthermore there is a magnification or minimisation of the significance of events in an unrealistic way, individuals will personalise events, inappropriately identifying meaning without any causal connection. Beck and Weishaar (1989) describe the goals of C B T as correcting distorted information processing and modifying the dysfunctional beliefs and assumptions that underpin dysfunctional affect and behaviour; ultimately to enable the individual to behave adaptively within any given circumstances, by equipping the individual with new skills and the ability to recognise and modified underlying assumptions, systematic thinking biases and further understand the interaction between thoughts feelings and behaviour.
In order to facilitate the process of change, intervention needs to target the cognitive behavioural and affective sphere. Therapeutic change occur through allowing the individual to experiment with change in their cognitive perspective which in turn promotes potential behavioural change through calculated risk-taking. New behaviours will in turn validate the new perspective. From this point emotional responses can be modified through weighing up the evidence and broadening of perspective to allow alternate interpretations to be formulated and the ensuing emotional flux allows cognitive change to proceed. The process is an interaction of the three spheres, with cognitions being the currency of change (Beck and Weishaar 1989)
According to Beck (1989) cognitive change occurs at a number of levels, forming a hierarchy of accessibility: voluntary or consciously accessible temporary thoughts, automatic thoughts, assumptions and at the core of one's belief system schema. Automatic thoughts are spontaneous, strong in their effect, they are intermediary between stimulus and the emotional and behavioural reaction. They are experienced as plausible rational thoughts logically consistent to the individual and accurate given that the affective response they elicit. Beck and Weishaar (1989) identify automatic thought as the windows to distortion in information processing and are representative of a person's beliefs and underlying assumptions. Assumptions are beliefs generated from an individual's experience of the world, there are how we conceptualise self and the world we inhabit. Beck and Weishaar (1989) state that assumptions shape perceptions into cognitions, generate goals and values whilst providing interpretation and meaning to situations. Assumptions are generally outside a person's awareness. The final layer of the hierarchy are schema; memory records of stimuli associated with emotional experiences encoded with subjective feeling and autonomic reactions. Schema integrate experience and provide a rapid automatic appraisal of new events and situations. Schema exist outside awareness (Brewin 1988)
Cognitive behaviour therapy is a collaborative venture, where the quality of clients - therapist alliance is highly significant; with therapist and client expected to be active and interactive within the relationship (Padesky 1996). The therapeutic framework of CBT allows the client to examine cognitions and subject them to reality testing. Examination of the evidence and logic which shore up dysfunctional cognitions gives the clients the opportunity to reframe potentially misconstrued situations, allowing the clients to challenge the strength and foundations of their beliefs and recognise the possibility of changing the way they look at and interpret events. Beck and Weishaar (1989) described this process as collaborative empiricism, with therapist acting as a guide to understanding the connection between thought, emotions and behaviour. The client assumes responsibility for goal setting by monitoring thoughts and images and with setting behavioural and cognitive ‘homework’ tasks. The aim is to test hypotheses based upon the clients' belief system, identify dysfunctional beliefs and distorted interpretations and look to modify those beliefs. This process is aided by the technique of guided discovery; a process of learning through a verbal questioning and experientially through experiment carried out in and outside of therapy sessions. Padesky(1996) describes it as the ’engine that drives learning in CBT’ (p271)
Application of CBT in psychiatric disorders requires each specific disorder to be conceptualise the within a CBT framework. Cognitive profile techniques are then applied to neutralise or reverse the distortions characteristic of the particular disorder. There has been an increasing body of knowledge being developed for the application of CBT in psychological treatment of schizophrenia. CBT was developed as a treatment intervention for ‘neurotic’ disorders for which a strong argument exists for environmental stressors being precipitative (Haddock and Tarrier 1996) ,whilst schizophrenia has a strong biological element, there is evidence which strongly suggests that the course of schizophrenia and the severity of its symptoms are influenced by stress.
A Vulnerability / Stress model is used to explain the interaction between biological and environmental factors and the effect upon symptomology is influenced by environmental stressors and personal resources. In addition the symptom’s experienced such as auditory hallucinations and delusional ideas generate distress which can be seen as symptoms of anxiety and depression. These emotional disorders; with their inherent cognitive distortions and increased arousal response, probably exacerbate psychosis and subsequently increase symptomology in a self-perpetuating cycle (Zubin and Spring 1997, Neuchterlein and Dawson 1984). Whilst CBT for psychosis shares many of the principles and actions of CBT for anxiety and depression it also has many differences due to the nature of psychosis, probably because the content of psychological processes which govern psychosis are different, but the way in which they are processed and subsequently regulated are so different because of the psychosis (Haddock et al 1990). The vulnerability / stress model offers a formulation of psychotic illness which recognises the biological influences on psychosis but also acknowledges the way behaviour, experiences and beliefs of people with psychosis may be shaped by psychological and social factors. Vulnerability / stress models imply the potential for buffering the influence of environmental and social stressors on individuals through pharmacological, social and psychological interventions. According to a Haddock and Tarrier (1998) focusing on the individuals’ information processing structures and its interactions with behavioural and physiological responses maybe with appropriate pharmacotherapy reduce psychotic phenomena and the associated distress.
Psychosis is a complex multi-dimensional disorder with marked differences from case to case. There are multiple factors involved in development and maintenance. A variety of interventions exist under the collective umbrella of CBT for psychosis with no single unambiguous definition (Jones et al 2001), the reality of CBT interventions in psychosis is that particular facets of the disorder at selected for intervention, it is not a panacea treatment but highly selective of treatment areas. The main body of research has been carried out in to CBT for chronic, medication resistance, unremitting hallucinations and delusions (Tarrier et al 1993,1998,2001, Kuipers et al 1997,1998, Garrity et al 1994,1997, Chadwick and Birchwood 1994, Chadwick et al 2000, Sensky et al 2000,), with further research looking into CBT interventions during the acute psychotic phase and the implications for hastening resolution of positive symptoms and reduction of residual symptoms (Drury et al 1996a, 1996b, 2000)
Traditionally delusional beliefs were believed to be fixed entities, held with absolute conviction, not amenable to modification and lacking in cultural determinants (Chadwick and Lowe 1990). However this view has been increasingly challenged and there is now evidence to support the idea that delusional beliefs are amenable to challenge and that the strength of conviction in those beliefs can in fact be modified. Chadwick and Lowe (1990) identified a marked reduction in delusional belief conviction using modified CBT techniques of verbal challenging in combination with reality testing in an atmosphere of collaborative empiricism. A number of studies have focused on the use of CBT techniques originally developed to challenge negative thinking in depression and subsequently adapted to apply to disorders of thinking, delusional ideas, hallucinations and affective symptoms associated with psychosis. Based upon Bentals’ (1991) theoretical model of psychosis which identifies reasoning and attributional biases that contribute to the formation of abnormal belief systems, suggesting reasoning processes are highly significant in the explanation and maintenance of beliefs. The implications are, that interventions designed to modified reasoning processes and strategies which enhance cognitive processes will be effective in reducing the depth of conviction of beliefs. Garrity and Kuipers et al (1994) conducted a study to obtain evidence for the effectiveness of CBT for psychosis. Using a control group receiving treatment as usual the experimental group received up to 22 sessions on a weekly or fortnightly basis over six months. Therapy was carried out by clinical psychologists, all trained in CBT and rehabilitation approaches for people with enduring psychotic disorders. Outcomes were promising, given the limitations of the study (small convenience sample, non-randomisation, comparatively short treatment duration), with a reported ‘remarkable’ reduction in delusional conviction in the majority of subjects treated. Reduction in levels of distress and preoccupation were also reported. As a result of the findings and their implications, a further study was commissioned; a large multicentre, randomised controlled trial, the aim being to offer CBT for a period of nine months to clients experiencing persistent, distressing, medication resistant symptoms of psychosis. A further stated the aim was to engage as many clients in therapy as possible. The close link between engagement and assessment serves two essential functions (Fowler et al 1997). A fundamental function is to establish a collaborative therapeutic relationship. A collaborative relationship develops from exploration of client beliefs based upon their understanding of their perception and associated beliefs that are not shared by others (Kingdom 1998). The therapist works to bridge the gulf that exists between the client and those around, through a process of exploring the clients’ beliefs and working towards gaining a better understanding of those beliefs and opening avenues of alternative explanations which will hold credibility to the client. Thus, the therapist conveys the fact that their problems are being taken seriously and that precipitative concerns will be addressed in the therapeutic process (Fowler et al 1997). Through a process of ‘ normalising’ symptoms by working together to clearly identify the problems presented, looking for and identifying potential cause and effect relationship between stressful situations and exacerbation of problems symptoms, and identifying the relationship between symptoms and affect, the client will feel understood. This in itself can reduce fear and confusion (Kingdom 1998). Core relationship skills associated with facilitating disclosure; such as active listening, clarifying and summarising, along with client centred expression of positive regard through empathy, warmth and being genuine are fundamental to the engagement process.
Characteristic of working with people with psychosis is the increased probability of experiencing difficulties in initiating, establishing and maintaining a working therapeutic relationship. Fowler et al (1995) suggest the best approach is to attempt an understanding of the problems from the clients perspective. The initial part of the therapeutic process involves a full assessment. Fowler et al (1995) recommend reviewing with the client, recent problems and how they have been dealt with, without making any assumptions about the context, even at delusional ideation should be taking initially at face value. Kingdon (1995) states that Socratic questioning is an essential tool in this early assessment and engagement. Padeski (1993) defines Socratic questioning as, asking the client’s questions which they have the knowledge to answer, in which information relevant to the issues is refocused to their attention through abstract concept, enabling the client to re-evaluate previous ideas, and if necessary construct a new conclusion. It is through this process of guided discovery that an understanding of circumstances that initiated the precipitation of a psychotic illness can be gained. Kingdon (1998) indicates that enabling the clients to obtain an understanding of when the symptoms develop and the circumstances leading up to an initial episode is crucial. Kingdon (1998) further suggests building up a personal history; with significant events plotted, will allow the client to make sense of events and may trigger the seed bed of faulty cognitions leading to delusional ideas, through a process of personalising, selective abstraction and arbitrary inference.
The use of formal assessment tools such as the Psychiatric Assessment Scale (Krawieka et al 1977) Beliefs About Voices Questionnaire (Chadwick and Birchwood 1995) and standard affective checklists such as Beck Depression Inventory (Beck 1978) and the Beck Hopelessness Scale (Beck et al 1974) can be used as ongoing assessment, and are valuable for both client and therapist in benchmarking, prioritising and gauging progress. Psychotic disorders are generally enduring in nature and can involve cognitive, psychological, social and vocational impairments and disabilities. Haddock and Tarrier (1998) advised inclusion of these aspects in the assessment process.
The outcome of the engagement and assessment period should be a good collaborative working relationship based on mutual trust and respect, with a full overview of symptoms and their severity. Cognitive behavioural assessment should include the antecedents and symptom context, including physiological, affective behavioural and cognitive consequences. Haddock and Tarrier (1998) identified the significance of the clients’ conceptualisation of the problems and acknowledge any positive aspects to the symptoms to enable a shared understanding of the clients' experience. Haddock and Tarrier (1998) suggest prioritisation of problems, looking at the issues of safety, risk and urgency, whilst giving full consideration to the levels of distress being generated. Client engagement and motivation will have a bearing on this.
According to Morrison (1998), CBT is an individually tailored therapy, it does not come as a standard package, techniques and guided by careful formulation of each individual's problems. Many clients will already have an explanation for the issues discussed during case formulation, which may or may not be delusional in nature. Schizophrenia is a complex disorder with no one causal trigger, but an interaction of biological predisposition, environmental and the psychological factors (Kingdom and Turkington 1994). An explanation of schizophrenic symptoms is fundamental to the use of CBT. An explanation which normalises the condition is required. Using the vulnerability \ stress model as a basis (Zubin and spring 1977), research has shown that hallucinatory phenomena is not necessarily an abnormal experience (Romme and Escher 1994), occuring in cases of sleep and sensory deprivation, grief and traumatic experience. Equally delusional ideas can be looked at from a cultural context. By offering an alternative perspective on these experiences, putting them in the context of a continuum within normal experience, and discussed in the context of vulnerability \ stress model, and significant life events immediately preceding initial and subsequent episodes, a significant rationalisation of subsequent events can be offered to the client. Kingdon (1998) identifies the risk of the therapist attempting to interpret meaning and significance into events, suggesting a process of guided discovery of significant events will allow the client to uncover any meaning, which they themselves feel is of significance.
A number of cognitive behavioural strategies may be used to reduce the distress and disability of an enduring psychotic disorder. Target symptoms include delusional ideas and hallucinations, despair and hopelessness, thought broadcasting and insertion, however the primary focus must be on the symptoms which cause the client the most distress and the greatest disability (Fowler et al). Cognitive behavioural strategies to assist with the clients self-regulation or coping strategies have been shown to aid the client enhance existing strategies. Coping has been defined by Tarrier et al (1993) as an active attempt or attempts to control, master or overcome the symptoms or the consequences of psychosis. Tarrier et al (1993) state that symptoms can be precipitated by environmental and social factors and those clients with schizophrenia and associated psychotic disorders have been demonstrated to develop coping strategies to alleviate their symptoms.
In relation to drug resistant hallucinations, the efficacy of Coping Strategy Enhancement (CSE) has been demonstrated as effective (Tarrier et al 1993,1998,2001, Haddock et al 1999), with clients receiving CSE through the medium of CBT, showing the greatest improvement in positive symptoms at a statistically significant level and a 50 per cent reduction in positive symptoms at the clinical level when compared with routine treatment. The study indicates a probability of eight times greater odds of this level of reduction when compared to routine care. Although reduction in the intensity and frequency of psychotic symptomology is an explicit aim of therapy, the primary aim is to enable the clients to build feelings of self control, which in turn help manage their experiences and difficulties and reduce distress, whilst increasing independence. Tarrier (1992) categorised coping strategies into four groups; cognitive strategies, behavioural strategies, modifying sensory input and physiological strategies. Individual analysis and formulation, of psychotic symptoms will indicate which strategies may be of particular use on an individual basis. If common antecedents to symptoms are identified the approaches which manage the antecedents most effectively can be utilised. Coping strategy enhancements involve building upon the clients' existing positive coping behaviours following detailed symptom analysis. It involves training in behavioural strategies, through guided practice during therapy sessions and mutually agreed upon graded homework sessions. Morrison (1998) describes it as an ‘ extremely pragmatic’ approach, with treatment targeting symptoms held with lesser conviction and further symptoms selected when a successful strategy has been developed and implemented. Fowler et al(1998) acknowledges limitations in the use of coping strategy interventions. Perceived omnipotence of voices and strongly held delusional ideas can mitigate against changing of existing strategies. Emotional reactions that precipitate anxiety can in turn reinforce delusional conviction. Kingdom (1998) suggests that anxiety and tension are often relieved by the activation of delusional thoughts as a defence; when doubt about the beliefs as adequate explanation for this situation emerge. Fowler et al (1998) suggest that adapting to triggered situations through adoption of improved strategies which may combine cognitive, behavioural, sensory or physiological coping skills are, a collection of usable and valid (to the client) strategies can be developed, and with the repeated practice be applied automatically when symptoms occur.
Morrison (1998) states that it is important to demonstrate the links between thoughts feelings and behaviour, and once established, for the client to monitor their thoughts. This can be done by identification of and rating of the strength emotional response, acknowledging the situation in which these emotions occurred and identifying the thought that accompanies these feelings. Morrison (1998) stresses the importance of recording the strength of conviction in these thoughts. Through a process of verbal re-attribution these thoughts are viewed as hypotheses to test and are equally as valid for use in delusional thoughts and hallucinations. Examining the evidence allows the client and therapist to scrutinise the available facts upon which the client bases their beliefs, this includes uncovering evidence contrary to their beliefs that may reduce conviction. Morrison (1998) supports the notion that people experiencing delusions have perceptual and interpretive biases. Given these biases, Morrison (1998) believes concentrating a clients' attention towards dis-confirming evidence is an important element in therapy. Padesky (1994) identifies the ease with which dysfunctional schemas are maintained; with much of CBT relying on belief modification through review and producing of new evidence which is contradictory to the conclusions the client has drawn up, Padesky (1994) states that the treatment of chronic problems involves both the testing of dysfunctional beliefs but also strengthening alternative adapted schema. Alternative schemas needed developing before the client can realistically question the existing schema. Fowler et al (1995) understands that the therapists task is to collaboratively develop a comprehensive understanding of the development of beliefs from the perspective of the client and to begin to understand the emotional consequences. Kingdom and Turkinton (1994) suggest a technique of inference chaining be used to identify ‘ hot cognitions’ or cognitions with the greatest emotional investment and attachment. This process will help discover underlying assumptive schema. Inference chaining is a process of identifying thoughts associated with distressing emotions through questioning the specific or idiosyncratic meaning of the thought, should it be true. The subsequent response is questioned in the same manner and so forth (see Appendix 1). The provision of an alternative explanation in combination with Socratic questioning can be used in an attempt to modify these cognitions.
In normal psychological processes individuals operate confirmatory biases, selective attention biases and memory bias (Padesky 1994),with these processes being exaggerated in delusional process. Information and education regarding these psychological processes is important as it will enable clients to gain recognition of them as will enable clients to gain recognition of them and act upon possible reversal to undermine these beliefs (Morrison 1998). Information regarding the interpretation of intrusive thoughts and imagery which may support the development and maintenance of delusional beliefs can, through gently challenging the evidence, create alternative explanations. Behavioural experiments enable belief systems to be loosened and allow the clients to learn that their interpretations are not necessarily fact but one way of viewing events. This educational exercise is also useful in providing a normalising rationale for stress exacerbation of symptoms and the role of autonomic responses in associated distress.
Morrison (1998) identifies an examination of the benefits and losses of holding on to beliefs. Certain beliefs; such as grandiose ideas, boost self-esteem and increase the sense of social importance and inclusion. There are also financial gains from the benefits system, adapting one's beliefs may infer a loss of eligibility for financial aid. Fowler et al (1995) suggest that delusions may have a protective value to the individual especially from emotional distress. The important factor here is to collaboratively assess fully the meanings associated with delusions and hallucinations; discuss the pros and cons of the continuation of these beliefs whilst emphasising that the goal of therapy is distress reduction and not a coercive change in beliefs.
Verbal reattribution should be followed as a matter of routine by behavioural retribution, as it creates a potent combination (Morrison 1998). Behavioural experiments may involve the client acting in ways that are contrary to the demands of the hallucinations and delusional beliefs. Carrying out these experiments can produce a change in behaviour which according to Kingdon (1994), produce consequences which may contradict beliefs and act towards reduction of belief conviction by allowing the clients; through collaborative empiricism, to challenge the validity of a particular belief and provide disconfirmatory evidence. The ability to predict an outcome, review the evidence for and against, and subject to a devised experiment is however dependent upon the nature and context of the delusion or hallucinatory experience.
The current body of evidence indicates that CBT can be effective in diminishing persistence positive symptoms and the associated distress in people with chronic psychosis. Kuipers et al (1997) provided CBT in weekly sessions over a nine month period. In addition to medication and case management the research group were offered Coping Strategy Enhancement, development of a shared model of psychosis, modification of delusional beliefs and beliefs about hallucinations, modification of dysfunctional schemas and management of disability and relapse. This therapy was measured against a control group who received routine case management and medication, one hundred and fifty two people were referred for possible inclusion however only sixty were able to meet inclusion criteria and consented to the trial, a further eighteen per cent dropped out of the trial. In an RCT study into the impact of CBT on recovery from acute psychosis (Drury et al 1996 a, 1996 p), one hundred and seventeen patients were screened for inclusion with only forty eventually entering the trial, a similar scenario is seen in the studies by Tarrier et al (1998), Haddock et al (1999). Johnson (1996) suggests that because of the high selectivity of clients suitable for therapy, any success shown is a therefore only in a small sub-group of patients with psychosis of positive symptoms and this needs acknowledging as it affects the external validity of the intervention. Johnson (1996) further states that even by accepting that the results as correct it is still only applicable to a relatively small minority of those in need. However the outcomes in both statistical terms and clinical measures indicate that CBT can be targeted effectively at distressing and debilitating symptoms of psychosis. Haddock et al (1999) indicated the feasibility of CBT for early onset acute psychosis, whilst Drury et al (1996 a 1996 p) demonstrated a marked reduction in positive symptoms over a twelve week period, with a high statistically significant difference between experimental and control groups within seven weeks. This was maintained through to week twelve of the study with a significantly faster rate of decline of positive symptoms compared with the control group. Delusional belief conviction and preoccupation was also noted to show a marked improvement. These improvements continued at nine months follow up with ninety five per cent of the CBT group reporting no or only minor delusional or hallucinatory experience as measured on the Psychiatric Assessment Scale (Krawieka et al 1977). Drury et al (1996 b) considered the high level of engagement in the CBT group to be a positive outcome, believing it linked to the feeling by the clients that their beliefs were engaged at directly, and not ignored or dismissed. Drury et al (1996) further suggests that the study demonstrated that delusional beliefs and hallucinations are driven by attempts to construct meanings from these experiences and it is in that search for meaning that CBT has its focus. The results of the study suggests that CBT can accelerate recovery from positive symptoms and lead to a lower level of residual symptoms both ‘quantitatively and qualitatively’ (Drury et al 1996 p) however at four year follow up, Drury et al (2000) found that there was no significant difference between the CBT group and control group on: relapse time, time in acute care or time to first relapse following index episode. However providing the experience of relapse could be minimised or avoided the CBT group had significant and enduring clinical benefits. Drury et al (2000) suggests brief treatment appears less effective on a long term disorder relevant intervention; reinforcing the importance of relapse prevention in the early period of psychosis.
Whilst intervention at the onset of psychosis shows promising results, the main body of studies have targeted chronic unremitting psychosis with resistance to medication. Kuipers et al (1997) and Garety et al (1997) in a multi-centre RCT, demonstrated improvements in; ideas of reference and persecution, delusional ideation and hallucinatory experience, although these did not meet statistical significance, improvements where apparent at clinical level. Kuipers et al (1997) concluded at the end of a nine month treatment period that it is possible to improve the overall symptomology of people with medication resistant, distressing symptoms of psychosis. Garety et al (1997) state that the results confirm the hypothesis that those clients assessed to have a certain cognitive flexibility; a readiness to consider alternatives, is a factor in effective CBT for delusions, and would therefore predict a good response to CBT. They further conclude that patients with delusions in some cases can consider alternatives and make use of evidence to re-evaluate their beliefs in line with the theory of delusional ideation being associated with cognitive biases in reasoning and other cognitive functions. Garety et al (1997) further speculate that therapy may provide compensatory methods that assist in re-evaluation of beliefs for clients whose cognitive biases lay a path to delusional ideation. At 18 months follow-up to the study Kuipers and Garety et al (1998) report maintained improvement in the CBT group and suggest these improvements are continuing with sixty five per cent of the CBT group showing reliable clinical improvement compared to seventeen per cent of the control group. This gives weight to the suggestion that improvement was not as a result of the attention affect but due to the specific treatment benefits of CBT. Kuipers et al (1998) identified evidence indicating that CBT; as an adjunct treatment, can be of benefit to those with medication resistance symptoms of psychosis and is a cost effective intervention for this client group. Tarrier et al (1998, 1999, 2001) present strong evidence to support the notion that CBT significantly decreases persistent positive psychotic symptoms, with CBT being superior to routine care in the treatment of delusions and hallucinations than supportive counselling, and significant differences in the reduction of thought disorder and negative symptoms when compared to routine care.
Jones et al (2001) in a Cochrane review identified some methodological weaknesses in all the RCT’s reviewed, notably the lack of double-blind assessment, opening up the opportunity for bias to emerge and the absence of prior calculations of statistical power in all but one study (Garety et al 1997). Jones et al (2001) identified the considerable investment of time involved in the intervention on both therapist and client part, citing Drury et al (1996) as providing an average of five hours per week of interventions including one to one and group sessions, adding that “even in well resource care cultures this degree of investment is rarely available to those with psychotic disorders willing to receive it”. Jones et al (2001) also questions whether CBT’s main effects were mediated by increased compliance with medication. Kemp et al (1996) in an RCT studying medication compliance used CBT derived motivational interviewing, which included guided discovery and problem solving with an educational component. The results showed the effectiveness of therapy in improving insight, attitudes and compliance, with gains maintained ”without erosion” after six months. Kemp et al (1996) further suggest that attitude to treatment has a bearing on compliance.
Despite the positive outcomes of robust research studies the availability of training for mental health professionals in CBT application for psychosis is limited. In all the current studies to date therapeutic interventions have been carried out by experienced clinical psychologists, acknowledged as experts in this form of treatment (Tarrier et al 1993,2001 Jakes et al 1999, Garety et al 1997, Kuipers et al 1997,). Haddock et al (2001) state that as a result of minimal training opportunities very few psychotic patients receive any sort of CBT in routine clinical practice. Jones et al (2001) further suggests that situation will remain until either CBT skills can be generalised for use by community nurses, or alternatively there is an increase in the availability of therapists practising with this specific client group.
Provision of mental health services bear little relation to research, with empirically validated treatments not widely available whilst treatments whose comparative effectiveness is equivocal at best are common practice (Tarrier et al 1998). Progression from innovative research to practice is necessary, with service providers investing in skills training programmes so that new clinically relevant treatments can meet prioritised and identified needs and are taught an accessible way Jones et al (2001) considers the need for continued research in this area important also as a potentially mitigating factor in the growth of training opportunities for health care professionals.